The Great Recession & - PowerPoint Presentation

Slide1

The Great Recession & Fiscal Allocation for Public Health:How Has Our Slice of The Pie Changed?

AuthorsJ. Mac McCullough, PhD, MPH

Assistant Professor

School for the Science of Health Care Delivery

Arizona State

University

JP Leider, PhD

Consultant, JP Leider Consulting LLC

Gulzar

Shah, PhD,

MStat

, MS

A

ssociate Dean for Research & Associate Professor

Jiann

-Ping Hsu College of Public Health

Georgia Southern University

Introduction & MotivationLocal sources of revenues are

important for LHD financial stability and may reflect local prioritization of public health relative to other

programs

Focus of most of the post recession studies have been to examine the changes in budgets regardless of sources of revenue

A local health department’s local

revenues are often evaluated relative to non-local revenues (e.g., % of revenues from local sources)A more informative comparison is an area’s local revenues for public health relative to other non-public health revenues“Fiscal allocation” for public health

Total LHD

Revenues

Revenues from

local sources

Total Local Public

Revenues

1

2

3

Research QuestionWhat is the local fiscal allocation for public health as of 2008?

What organizational or jurisdictional factors are associated with higher fiscal allocation?

How has fiscal allocation for public health changed since before the Great Recession?

What organizational or jurisdictional factors are associated with higher levels of fiscal allocation retention?

Especially important at the extremes (what separates the big gains from the big declines?)

MethodsData sources:

Local governmental revenue data from U.S. Census of Local Governments (2007 & 2012)

Contains geographic and financial data on 87,000 local governments (cities, counties, school districts, special districts, etc.)

LHD data from NACCHO Profile survey (2008 & 2013)

Matched using FIPS codes, excluded LHDs with missing/unreliable expenditure data

# LHDs in sample in both years: n = 983 LHDsOutcome of interest:Fiscal Allocation = (Total LHD Local Revenue) ÷ (Total Local taxes for corresponding local governments)Local revenue expenditure data self-reported to NACCHO by LHDsLocal taxes include: property taxes, other collected taxes, fees, fines2007, 2012, and change between 07-12Univariate, bivariate, multivariate analyses

Also compute models stratified by level of long-term debt

ResultsFiscal allocation varies widely across LHDsLarge number of LHDs receive no fiscal allocation

Small number of LHDs receive high fiscal allocation

Substantial state-level variation

Correlates of Fiscal Allocation in 2007

LHD or Area Characteristic

Association with F

iscal Allocation

Single-county LHD

jurisdiction (versus all other jurisdiction types)Single county jurisdiction

 0.80 percentage point higher Fiscal AllocationLHD has a Local Board of

Health (versus no LBOH)

LBOH  1.84 percentage point higher Fiscal Allocation

LHD per capita revenues

(standardized)

~$40

increase of per cap revenues  2.38 percentage point higher Fiscal Allocation

# of Services

Provided by LHD

1 additional service provided



0.09

percentage point higher Fiscal Allocation

Variables not significant in model:

Setting (urban, suburban, rural), % of population that is Non-White,

LHD authority to set and

impose fees for public health, LHD authority to impose taxes for public health, LHD authority to request tax levy for public health, number of services provided by state, number of services provided by other local government, number of services not available in area

Estimates correspond to the predicted percentage point change in fiscal allocation for presence or one-unit increase for each factor

Changes in Fiscal Allocation

Lots of small changes before versus after the Great Recession

Small negative changes more frequent than small positive changes, but…

There were LHDs that managed to increase their fiscal allocation from 2007 to

2012!

Were these LHDs just “lucky” or are there patterns lurking in the data?

Correlates of Changes in Fiscal AllocationFactors associated with increased likelihood of having a “large” decline in FA from 2007-12:

Higher percent population served that is non-white (OR = 1.02*)

Greater number of public health activities provided by the

state

health department (OR = 1.05**)

Higher baseline fiscal allocation (OR = 1.09**)Factors associated with lower likelihood of having a “large” decline in FA from 2007-12:Greater number of public health activities provided by the local health department (OR = 0.97**)Other factors included in the model (not significantly associated)Urban/Suburban/Rural; Population served; Single-county jurisdiction; Presence of LBOH; Per capita expenditures; Jurisdictional authority to levy taxes for public health; Number of public health activities provided by other entities; Number of public health activities not available in jurisdiction.

Correlates of Changes in Fiscal AllocationPrevious slide discussed likelihood of “large” changes (> |25%|). What about smaller changes?In addition to previous (% jurisdiction that is non

-white, # PH activities provided by LHD and by state):

Compared to rural LHDs, urban LHDs had larger declines

BUT, area’s Long-Term Debt serves as moderator to many of these relationships!

Association between percent non-white and decline in FA only holds in areas with high debt

Associations between state and local service provision and changes in FA only hold in areas with low debtIn addition, suburban LHDs and jurisdictions with the ability to set and impose fees for public health saw gains in FA compared to their counterparts.

Implications & Next Steps

Fiscal Allocation for LHDsFiscal allocation for public health averages approximately 3.3% of all local governmental “own revenues”

High variation within and between states

The Great Recession not only resulted in a smaller overall pie, but public health now receives a smaller piece of that pie.

Takeaways for Practitioners & Implications for Health EquityA range of factors are associated with levels of fiscal allocation for public health

LHD jurisdiction type, governance, expenditures, service provision

Some are amenable to LHD leadership intervention (e.g., service provision), others are harder to impact

From health equity and disparities perspective:

Findings that areas with high proportion of non-white population and high levels of long-term debt were prone to declines in FA during the Great Recession may be concerning.

Suburban LHDs, those able to set their own fees, and those providing higher number of direct services tended to fare better.

Impacts of Long-Term Debt on LHDsAnecdotally, we generally understand that very high levels of long-term debt is bad

Less room for other priorities

Less flexibility to match current needs

Public health is not immune  An area’s long-term debt level is extremely important

Areas with high long-term debt tend to have lower fiscal allocation for public health

Only know which levers are relevant/effective after considering long-term debtTake AwayResearchers: also consider additional financial measures beyond per capita revenuePolicy Makers: what local tax and debt conditions are most conducive to advocacy for increased funding? What areas may be especially prone to erosion of local funding during future economic recessions?

Thank YouQuestions?mccullough@asu.edu